Prevalence of alcohol, illicit drugs and psychoactive medicines in killed drivers in four European countries.

Our objective was to determine the presence of psychoactive substances in blood of drivers killed in road crashes in four European countries. Data from 1118 drivers of car and vans, killed between 2006 and 2009, were collected in Finland, Norway, Portugal and Sweden. The prevalence of any psychoactive substance ranged between 31 and 48%. Alcohol (≥ 0.1 g/L) was the most common finding, 87% had a blood alcohol concentration (BAC) ≥ .5 g/L. Benzodiazepines (1.8-13.3%) and amphetamines (0-7.4%) were the most prevalent psychoactive medicines and illicit drugs, respectively. Alcohol-drug and drug-drug combinations were rather prevalent. Differences in alcohol/drug findings seemed to reflect differences in use in the countries. More research should be done to develop preventive strategies to reduce the number of alcohol- and drug-related traffic accidents targeting at-risk groups, such as drivers with very high BACs and novice drivers.

Comparison between self-report of cannabis use and toxicological detection of THC/THCCOOH in blood and THC in oral fluid in drivers in a roadside survey.

The objective of this study was to compare the number of drivers who self-reported cannabis use by questionnaires to the results of toxicological analysis. During roadside surveys, 2957 respondents driving a personal car or van completed a questionnaire to report their use of drugs and medicines during the previous two weeks and to indicate the time of their last intake. Cannabis was analyzed in oral fluid by ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS), in blood by gas chromatography-mass spectrometry (GC-MS). Frequencies in the time categories were calculated and compared with toxicological results. Diagnostic values were calculated for the time categories in which positive findings were to be expected (<4 h and <2 4h, respectively for tetrahydrocannabinol (THC) and delta9-tetrahydrocannabinol (THCCOOH) in blood, <12 h for THC in oral fluid). Most self-reported cannabis use was more than 12 h before driving. The sensitivity of the questionnaire was low, while the specificity and accuracy were high. Kappa statistics revealed a fair agreement between self-report and positive findings for THC in oral fluid and blood and moderate agreement with THCCOOH in blood. Self-report largely underestimates driving under the influence of cannabis, particularly recent cannabis use; therefore analysis of biological samples is necessary.

Comparison of drug concentrations measured in roadside surveys and in seriously injured drivers in Belgium.

The objective of this paper is to compare concentrations of alcohol, illicit, and medicinal drugs in seriously injured drivers and drivers selected randomly at the roadside. Blood samples were analyzed for alcohol, 17 medicinal drugs and 8 illicit psychoactive substances and/or their metabolites by ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) and gas chromatography mass spectrometry (GC-MS) in injured drivers admitted to the emergency departments of five hospitals in Belgium between January 2008 and May 2010 and in drivers randomly selected between January 2008 and September 2009. Three hundred and seventy-seven seriously injured drivers and 2750 roadside respondents were selected. In the roadside survey, out of the 203 concentrations above DRUID (Driving Under the Influence of Drugs, Alcohol and Medicines) cut-offs for medicinal drugs, 51% were in the therapeutic range, 46% infratherapeutic, and 2.5% supratherapeutic. In the seriously injured drivers, out of the 78 concentrations above DRUID cut-offs for medicinal drugs, these percentages were respectively 63%, 33%, and 4%. Significant differences were found in the distribution of concentrations for opioids, benzodiazepines, and Z-drugs. For the latter, while in the seriously injured drivers study most concentrations were therapeutic, in the roadside survey most were infratherapeutic. The opposite was observed for the opioids. Eight and 41% of the roadside respondents and injured drivers, respectively, had an alcohol concentration above 0.1 g/L, with higher concentrations found in the injured drivers. For illicit drugs, significant differences were found for amphetamine and cocaine, for which respectively lower and higher concentrations were observed in the blood samples taken in the roadside survey.

DUID: oral fluid and blood confirmation compared in Belgium.

The objective of this study was to compare the number of drivers with drug concentrations above the legal cutoffs for driving under the influence of illicit substances in paired samples of blood and oral fluid. Between January 2008 and September 2009, 2,949 randomly selected drivers participated in a roadside survey. Each was asked to provide blood and oral fluid. Samples were analyzed for 11 illicit substances or metabolites by ultra-performance liquid chromatography-tandem mass spectrometry and gas chromatography-tandem mass spectrometry. Out of the 2,750 drivers who gave both blood and oral fluid, 28 (1.0%) had drug concentrations above the legal cutoff in blood and 71 (2.6%) were above the legal cutoff in oral fluid. Fifteen (7.5%) of the 199 drivers who gave an oral fluid sample but refused to provide blood tested positive, significantly more than drivers who provided both samples. Based on oral fluid analysis, 2.6 times more subjects tested positive for drugs compared to blood analysis. Those that refused to give a blood sample were 3 times more likely to test positive for drugs. Even in a survey that guaranteed total anonymity, people fearing a positive test result might have been more likely to refuse to give a blood sample.

A European approach to categorizing medicines for fitness to drive: outcomes of the DRUID project.

AIMS: To illustrate (i) the criteria and the development of the DRUID categorization system, (ii) the number of medicines that have currently been categorized, (iii) the added value of the DRUID categorization system and (iv) the next steps in the implementation of the DRUID system. METHODS: The development of the DRUID categorization system was based on several criteria. The following steps were considered: (i) conditions of use of the medicine, (ii) pharmacodynamic and pharmacokinetic data, (iii) pharmacovigilance data, including prevalence of undesirable effects, (iv) experimental and epidemiological data, (v) additional data derived from the patient information leaflet, existing categorization systems and (vi) final categorization. DRUID proposed four tiered categories for medicines and driving. RESULTS: In total, 3054 medicines were reviewed and over 1541 medicines were categorized (the rest were no longer on the EU market). Nearly half of the 1541 medicines were categorized 0 (no or negligible influence on fitness to drive), about 26% were placed in category I (minor influence on fitness to drive) and 17% were categorized as II or III (moderate or severe influence on fitness to drive). CONCLUSIONS: The current DRUID categorization system established and defined standardized and harmonized criteria to categorize commonly used medications, based on their influence on fitness to drive. Further efforts are needed to implement the DRUID categorization system at a European level and further activities should be undertaken in order to reinforce the awareness of health care professionals and patients on the effects of medicines on fitness to drive.

Analytical evaluation of four on-site oral fluid drug testing devices.

The use of oral fluid (OF) as an alternative matrix for the detection of drugs of abuse has increased over the last decade, leading to the need for a rapid, simple, and reliable on-site OF testing device. Four on-site OF drug testing devices (Dräger DrugTest 5000, Cozart DDS, Mavand Rapid STAT, and Innovacon OrAlert) were evaluated on 408 volunteers at drug treatment centers. UPLC-MS-MS results were used as reference to determine sensitivity, specificity and accuracy for each device, applying Belgian legal confirmation cutoffs for benzoylecgonine, cocaine, and THC (10 ng/mL); morphine and 6-acetylmorphine (5 ng/mL); and amphetamine and 3,4-methylenedioxymethylamphetamine (25 ng/mL). Sensitivity for cocaine was 50%, 50%, 27%, and 11% for DrugTest, OrAlert, Rapid STAT, and DDS 806, respectively. For opiates, sensitivities were 84%, 73%, 77%, and 65%, respectively. For THC, the sensitivities were 81%, 23%, 43%, and 28%, respectively. For amphetamines, the sensitivities were 75%, 33%, 17%, and 67%, respectively. Specificity was >88% for opiates and THC, > 90% for amphetamines, and > 97% for cocaine. All tests showed good specificity. DrugTest had the highest sensitivity, although it was still low for some analytes.

An analytical evaluation of eight on-site oral fluid drug screening devices using laboratory confirmation results from oral fluid.

The performance of eight on-site oral fluid drug screening devices was studied in Belgium, Finland and the Netherlands as a part of the EU-project DRUID. The main objective of the study was to evaluate the reliability of the devices for testing drivers suspected of driving under the influence of drugs (DUID). The performance of the devices was assessed by their ability to detect substances using cut-offs which were set at sufficiently low levels to allow optimal detection of positive DUID cases. The devices were evaluated for the detection of amphetamine(s), cannabis, cocaine, opiates and benzodiazepines when the relevant test was incorporated. Methamphetamine, MDMA and PCP tests that were included in some devices were not evaluated since there were too few positive samples. The device results were compared with confirmation analysis results in oral fluid. The opiates tests appeared to perform relatively well with sensitivity results between 69 and 90%. Amphetamines and benzodiazepines tests had lower sensitivity, although the DrugWipe test evaluated was promising for amphetamine. In particular, it is evident that the cannabis and cocaine tests of the devices still lack sensitivity, although further testing of the cocaine tests is desirable due to the low prevalence and low concentrations encountered in this study.